Tackling the Opioid Crisis: Bipartisan Policy Center’s Dr. Anand Parekh Examines State-Based Approaches
Dr. Anand Parekh
[Music]
Female: Welcome to Conversations on Health Care with Mark M asselli and
Margaret F linter, a show where we speak to the top thought leaders
in health innovation, health policy, care delivery and the great minds
who are shaping the health care of the future. This week M ark and
Margaret speak with Dr. Anand Parekh , Chief Medical A dvisor for the
Bipartisan Policy Center , a think tank dedicated to finding bipartisan
solutions to America's biggest policy challenges including health care.
He discusses their first of its kind reports on how different states are
utilizing federal dollars to battle the opioid crisis and what's working
in their states.
L ori Robertson also checks in the Managing Editor of F act C heck .org
looks at mis statement spoken about health po licy in the public
domain separating the faith from the facts . We end with a bright idea
that's improving health and wellbeing and everyday lives. If you have
comments, please email us at [email protected] or find u s on
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can also hear us by asking Alexa to play the program C onversations on
H ealth C are. Now stay tuned for our interview with Dr. A nand Parekh,
Chief Medical A dvisor to the Bipartisan Polic y Center on
C onversations on H ealth Care .
Mark Masselli: We're speaking today with Dr. Anand Par ekh a Chief Medical A dvisor
to the Bipartisan Policy Center, a Washington based t hink t ank
committed to promoting bipartisanship and policy decisions that
affec t all Americans. Dr. Parekh previously served as Deputy Assistant
Secretary for Health at the US Department of Health and Human
Services. He's a board certified in internal medicine and is a fellow of
the American College of Physicians. Dr. Parekh is an ad junct professor
at Johns Hopkins University, as well as the University of Michigan
School of Public Health. He received a BA in political science and MD
and an MPH in health management and policy from the University of
Michigan . Dr. Parekh w elcome to C onve rsations on Health Care .
Dr. Anand Parekh: Thank you , glad to be on with you.
Mark Masselli: Yeah, I think we're excited, Margaret, when we hear the word
bipartisanship i n terms of public health policy, it's so important and
probably no greater crisis faci ng Americans where we need
bipartisanship is the opioid crisis. R eally one of the great public health
crisis is the country is faced with more than 70,000 people dying from
overdose over last year. T he federal government is responding by
deploying billions of dollars to help states address the problem. Y our
team at the Bipartisan Policy Center has really focused in on creating
a comprehensive, transparent study analyzing how these federal
dollars are being spent at the state level. I'm wondering if you coul d
just talk to our listeners a little bit about this, first of its kind report
Dr. Anand Parekh
and why this information is so important.
Dr. Anand Parekh: You know, our purpose for this report is really to identify how federal
dollars are being spent on the opioid epidemi c. O ne would think that
this ought to be a government function , b ut it hadn't been done
before to our knowledge , a nd so we thought that it was important .
C ertainly a critical public health issue , i t's a bipartisan issue as well. It
is the first comprehensi ve transparent study tracking federal funding
streams to help states and localities tackle the opioid epidemic.
T hrough our study, we identified 67 different funding streams, areas
such as prevention, treatment, recovery, research, law enforcement,
interdi ction, criminal justice, so a broad range of areas. T hese
programs accounted for about $11 billion in federal funding. A
notable finding was between 2017 and 2018 there was a significant
increase in the amount of funding for treatment and recovery
specific ally , a nd that's appropriate given the high numbers of
Americans who have opioid use disorder.
Margaret Flinter: Well, I understand that your study looked at five geographically
diverse states and looked at the kind of infrastructure that each one
was buil ding to address the opioid crisis in their communities and how
they were really thinking about and allocating their federal dollars to
do so. Can you share with us some of the more notable findings and
what worked well, what didn't or still in process.
Dr. Anand Parekh: We look specifically at five states, we looked at Arizona, Louisiana,
Tennessee, Ohio, and New Hampshire. W e wanted to make sure that
these were five different states. They are also politically diverse
[inaudible 00:04:32 ] expanded Medicaid, which I'm sure we'll get into
others have not . B ut as a whole, they have a significantly higher
opioid overdose death rate. T here are really two critical findings , a nd
the first finding, federal opioid funding in the states is flowing the
counties with th e highest number of drug overdose deaths, and that's
a positive finding.
The second finding was that many rural counties seem to receive
lower levels of per capita f unding in spite of some of these actually
having pretty high drug overdose death rates. T ha t really points to
this issue that we need to continue focusing on vulnerable
communities, particularly in rural America where there is limited
treatment infrastructure and workforce capacity. Now, we saw a lot
of best practices , f or example, in New Hampsh ire, where they have a
significant area that is quite rural. T hey are integrating a hub - and -
spoke model, which is essentially a way to ensure that there are a few
hubs in the state where complex cases individuals who have opioid
use sort of can go. B ut the n there are many spokes that allow any
individual in state within one hour, they would be able to reach a
treatm ent facility, s o it's one way of increasing access to treatment.
Dr. Anand Parekh
Other states like Ohio, in some communities, law enforcement and
public health teamed up. R ight after there's an overdose, in the
substance 24 or 48 hours, there's a team of health professionals who
go to the home of the individual who's overdosed and try to see if
they would welcome treatment. S ome of these communities are
reporting incredible rates of entry and then retention into opioid use
disorder treatment with the gold standard treatment, which is
Medicaid assisted treatment . O ther states like Tennessee have seen a
dramatic reduction in the rate of opioid prescribing some of wh ich, as
we know, is unnecessary. That's a trend that's going on nationally.
In Louisiana, for example, there's a focus on incarcerated populations,
which is also vulnerable population . W e know that if we can get
treatment to individuals who are incarcerate d who have opioid use
disorder . T hen we know that upon re entry their overdose rates are
lower. W e found quite a few examples of innovation in the s tates,
four out of the five states that we explore did expand Medicaid, a nd
you can see a difference, you kn ow, the states that expanded are able
to get treatment to greater numbers of individuals who have opioid
use disorder.
Mark Masselli: Dr. Pa rekh I think you said it so eloquently t his is the gold standard
out there is medication assisted treatment, better known as MA Ts,
such an effective tool in managing substance abuse disorder. I'm
wondering if you could talk about what you learn from those
communities that deployed an integrated approach to treatment,
which included M A T .
Dr. Anand Parekh: T he evidence is pretty clear now that medica tion assisted treatment,
so it's the medication plus the behavioral counseling together, leads
to the highest rates of recovery. I think this idea that addiction, we
need to think of these as chronic diseases , what we learned i n quite
candidly, there are still communities across this country that are
hesitant about medication assisted treatment . T his may be due to the
fact that even these medications ar e partial opioid, what we call
agonist. I f you take a medication like Suboxon e, you can't become
dependent or addicted on these medications. These are really proven
evidence based treatments to treat opioid use disorder. I think just
getting that information out, I think is critical.
F ederal policies here are very helpful as well , a nd we were very
pleased to see that the Substance Abuse and Mental Health Services
Administration SAM H SA , in their key grant mandated that states have
to use their treatment dollars toward medication assisted treatment,
which is the gold standard. When we talk about MAT , that's the
treatment piece , b ut I think what we're now increasingly
understanding that it has to be treatment plus recovery, that it's MAT
plus housing and employment and all of those elements to recovery
Dr. Anand Parekh
that help individuals stay in trea tment that I think lead to the best
long term outcomes.
Margaret Flinter: Within our health system, the full integration of primary care, and
behavioral health and substance use disorder including M A T and
trying to advance the ranks of providers who are tr ained, eligible and
willing to engage in M A T treatment has really made a big difference. I
also want to thank you for flagging this role that Medicaid expansion
seems to have played in getting people into treatment. I t raises the
question, so what will we as a country do for those states that did not
expand Medicaid coverage . In fact, M a rk just today, one of our staff
were telling me how high the copay is under somebody who has
commercial insurance but can't afford the Suboxone because of it. I'm
wondering what are we going to do for those folks living in the non -
Medicaid expansion states?
Dr. Anand Parekh: I think that is a challenge that the non - Medicaid expansion states are
grappling with right now, because th ey see these federal revenue
streams coming in , these are discretionary dollars. But given that they
have an expanded Medicaid to help pay for treatment, essentially
these streams are going to pay for that treatment, when one would
hope that it was actually a private payer or a public payer. N ow you
a re seeing some states that have held out to date now partially
expanding Medicaid. I think this is increasingly becoming less of a
partisan issue , a nd you're seeing on both sides in red states and blue
states 35 to 50% of the treatment dollars in some of t he hardest hit
states come from Medicaid . S trengthening Medicaid strengthen to
respond to the opi oid epidemic.
B eyond expansion, there are other critical issues such as how do you
make sure that just because somebody has health insurance there
aren't, for example, prior authorizations, making it difficult, for
example, to get the medications that are needed , s o I think that's an
issue. But it's going to take public and private payer coverage of
treatment. T hat will then allow a lot of the discretionary stre ams that
B PC studied in its report that come in behind to help build what we
need for the long term for this broader addiction crisis, which is to
build the infrastructure.
Mark Masselli: We're speaking today with Dr. Anand Parekh , Chief Medical A dvisor to
the Bipartisan Policy Center , a Washington based t hink t ank
committed to promoting bipartisanship in American policy decision.
Dr. Parekh we talk about this combination of treatment and recovery
support being critical to the successful intervention. C lear ly we see
that concerns about the lack of access behavioral health services
remains a huge stumbling block. You talked earlier about the role that
SAMHSA, the Substance Abuse and Mental Health Administration is
playing in . C onnect the dots for us, if you w ill, about their integration
Dr. Anand Parekh
with the White House Office of D rug P olicy, and to really improve the
framework out of which local efforts can occur.
Dr. Anand Parekh: I think there are several critical points w hen we think about how do
you improve access to behavioral health services, certainly access to
health insurance is critical parity, ensuring that insurance companies
are providing the same level of coverage for mental health services as
they do as physical health services. Addressing stigma, I think is
critical having the workforce to provide the care. I f you think about
the federal response, there are multiple agencies involved , so
SAMSHA is one, HRSA which is the Health Resource Services
Administration overse es workforce programs, community health
cen ters, the Veterans Affairs D epartment, CMS Center for Medicare
and Medicaid S ervices . All of these federal agencies play a critical role
in improving access to behavioral he alth services .
I think a critical point of BPC’s report was that to coordinate the
efforts of all of these entities you need a rob ust empowered White
House Office of Drug Control p olicy . Y ou can imagine if you're a state
official, and you're seeing 5 7 different programs from the federal
government coming your way, unless there's coordina tion at the
federal level, how can we expect coordination at the state level? I
think that's why one of our key recommendations is that, again, th at
White House Office, be empowered to provide the coordination
across all of these federal agencies.
Margaret Flinter: Well, let me ask if you could comment on a very compelling piece that
you wrote last year, titled , h ow can we fix the opioid crisis . J ust kind
of lay out a couple of the key recommendations , one seems so
obvious, but get clinicians to prescribe f ewer opioids . H onestly, there
are some pretty good evidence that is happening, certainly reducing
barriers to treatment . We encounter many places that have kind of
zero tolerance for any complicating factors as opposed to a sort of
harm reduction model and treatment. Certainly the push to hold the
makers of these addictive drugs accountable may play a role. L ast,
how do we stop the flow of illegal substances like black market
F entanyl . T his is a very broad r ange of strategic interventions, b ut
they all seem to play an important role. I'd wonder if you'd like to
elaborate on any of them.
Dr. Anand Parekh: You know, in this country we have made it much easier to prescribe
opioids th an to prescribe the medications to treat opioid use disorder.
F or example, to p rescribe opioids, all I need to do is every three years
renew my DEA license, and that form takes about five minutes, and
you send in a check. T hen you essentially have a carte blanche, the
federal level to prescribe opioids . To prescribed the treatment fo r
opioid use disorder, you actually have to go through an eight hour
training to prescribe B uprenorphine, and then you have taps on the
Dr. Anand Parekh
number of individuals you can treat. Imagine if somebody told me ,
w ell, you can only see 100 patients with diabetes, or 50 patients with
heart failure, and they make it much more difficult to prescribe
treatment , a nd they make it quite easy to prescribe unnecessary
opioids.
Now, Margaret, you're absolutely right, we have made some progress
in reducing unnecessary prescripti ons in this country . B ack in 2012,
about 250 million opioid prescriptions annually , a nd now we've got
that down to below 200 million , closer to about 190 million
prescriptions. Still, there has been a significant over 20% reduction , s o
that's good. W e need to be mindful of the fact that there are
individuals in this country suffering from pain syndromes who have
chronic pain and individuals who for whom opioids are the correct
treatment. But we know that there's tremendous prescribing of
unnecessary opioids a nd that's what we're trying to get under control.
But I think tying in some sort of requirement or training, every time a
provider renews their DEA license where they get some kind of
continuing education on addiction, or opioid prescribing or opioid use
disorder and treatment, I think would be really helpful.
R educing some of these regulations that make it just that much more
difficult to prescribe medication assisted treatment for opioid use
disorder, I think really ought to be looked at. But then, as y ou said,
that ’s just one piece of the puzzle, but we also need to curb the illicit
flow. Y ou're absolutely right, F entanyl is what is driving overdose
deaths n ow in this country . W e need to get people in a treatment, we
need to support harm reduction strat egies, like ensuring that
Naloxone is distributed widely. They're all critical , i t has to be across
the board prevention, of course, is critical -- a critical ways to tackle
the epidemic .
Mark Masselli: Dr. Par ekh I want to end where we began, which is the word
bipartisanship. I wonder if you could just share with our listeners, not
all of them may know about the incredible forming of the Bipartisan
Policy Center, where it came from, and maybe some of its broader
work that bring you to the tables with a thi nkers from both sides of
the aisle.
Dr. Anand Parekh: I, like many of my colleagues here are driven towards the Bipartisan
Policy Center because we believe in the mission . F rankly, we think
there are ought to be more bipartisanship in this country. W e're
t hankful to the founders, Senator Tom Daschle, Senator George
Mitchell, Senator Howard Baker and S enator B ob D ole for helping
create the center, which essentially allows us to take the best ideas
from both political parties to promote health, to promote sec urity and
to promote opportunity. T he opioid epidemic is a bipartisan issue , a nd
God knows we need more bipartisanship in this country.
Dr. Anand Parekh
I have been pleased with the scientific leadership at H ealth and
Human Service Agencies . I think Commissioner Gottlieb h as done a
great job at FDA has been zero it in on the opioid epidemic. There is
good leadership across the scientific agencies. I do come back to the
Office of National Drug Control Policy at the White House, because I
do think there's an opportunity for t his administration right now to
really empower that office. T hen I think, finally c ongress has and is
playing a critical role in this response . W hat we heard from state s
while many of these funding streams, most of them are annual or one
time appropriation s. O ne of the key findings f rom our report was a
sustainable funding is critical.
Another finding was that flexible funding is also important. W e went
to some of these states to talk about the opioid epidemic , a nd they
started talking about methamphetamine abuse. S tates need to be
equipped at times to be able to deal with multiple drug abuse
epidemics a t the same time. We need bipartisanship in c ongress and
any administration coming in needs to keep their eye on the ball and
stay committed to this issue.
Ma rgaret Flinter: We've been speaking today with Dr. A nand Parekh , Chief Medical
A dvisor to the Bipartisan Policy Center, a Washington based t hink
t ank that's committed to promoting bipartisanship and American
policy decisions. You can access Dr. P arekh’s r e port by going to
B ipartisan P olicy.org . Y ou can follow him on T witter by going to @ A.
Parekh BPC or follow the organization @BPC_Bipartisan . Dr. Parekh
we want ed to thank you for your dedication to improving health
policy , advancing public health to savin g lives during this opioid crisis
and for joining us on C onversations on H ealth C are today.
Dr. Anand Parekh: Thank you, Margaret. Thank you, Mar k .
[Music]
Mark Masselli: At C onversations on Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori R obertson is an award - winning journalist and Managing
Editor of F act C heck .o rg a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics . Lori ,
what have you got for us this week?
Lori Robertson: I n the midst of a chicken pox outbreak in his state. Kentucky Governor
Matt Bevin said in a radio interview that he had not vaccinated any of
his children against the disease, choosing instead to purpose ly expose
his kids to an infected person to get chickenpox. P ublic health officials
say that practice is dangerous. According to his campaign website,
Bevin has nine children between the ages of 5 and 16. His office did
not reply to our request for additio nal comments. Eugene Shapiro, a
P rofessor of P ediatrics and Epidemiology at the Yale School of Public
Dr. Anand Parekh
Health told us that in the past, some doctors recommended so called
chickenpox parties with the idea of making sure a person gets
chickenpox as a child an d not as an adult when the disease is usually
much worse. Now that there's a vaccine that protects against the
disease, Shapiro said deliberate exposure is , quote, foolish to do.
That's because while most kids who get chickenpox are fine after a
few days o f itching and scratching, there can be complications,
including serious skin infections, brain inflammation and even death .
I n the early 1990s b efore the first vaccine was licensed, around
12,000 people were hospitalized , and between 100 and 150 died
every year a ccording to the Centers for Disease Control and
Prevention, which strongly recommends against chickenpox parties .
Bevin made other false or misleading statements in his interview, he
said that the people catching and spreading chicken box had been
v accinated calling this an example of irony , because vaccines don't
work 100% of the time, and the vast majority of children are
vaccinated in the United States. It's entirely possible for more
vaccinated than unvaccinated people to get chickenpox. There's no
irony involved, just math. Bevin also falsely claimed that people who
are vaccinated against chickenpox, quote, need to keep getting
boosters. There is no evidence that boosters are needed after a
person receives the two recommended doses of the vaccine . T hat's
my fact check for this week. I'm Lori Robertson, Managing Editor of
F act C heck.org .
Margaret Flinter: FactCeck.org i s committed to factual accuracy from the country's
major political players and i s a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, email us at CHC radio.com , we’ll have F act C hec k.org’s
Lori Robertson check it out for you here on C onversation.
[Music]
Margaret Flinter: Each week C onversations highlights a brigh t idea about how to make
wellness a part of our communities and everyday lives. While more
than 20 million Americans have gained coverage under the Affordable
Care Act, some 30 million remain uninsured and many of these are
either immigrants or without the resources to purchase coverage.
While most c am access primary health care in the nation's community
health centers and safety net hospitals, many more with complex
conditions simply can't afford access to specialty care . E ntrepreneur
[inaudible 00:23:35 ] decided to create a virtual way to bypass the
system and founded the human diagnosis project . A network of
volunteer specialists around the country offering virtual consults for
the neediest patients .
Male: The human diagnosis project is an online system b uilt by the world's
doctors to understand the best steps to help any patient . W e realized
Dr. Anand Parekh
that there is an opportunity to develop a system that can ultimately
help solve the problem for those people who won't have access to
specialty care.
Margaret Flinter : Dr. Shantanu Nundy is D irector of the Human Diagnosis Project . He's
a frontline primary care provider in a safety net clinic who saw the
opportunity to provide specialty care in a cost effective way t hrough
volunteer participation from specialist . A fre e online portal, linking
safety net providers serving underserved populations to specialty care
expertise. Now that's a bright idea.
Mark Masselli: You've been listening to C onversations on H ealth C are I’m Mark
Masselli.
Margaret Flinter: And I 'm M argaret Flinter.
Mark Masselli: Peace and health.
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